Karkara Kids Capoeira Afterschool Program

Karkara Kids Capoeira Afterschool Program 2016-2017 Student s Name: Today s Date: / / Address: Email Address: Mother s Name: Cell Phone: Father s Name: Cell Phone: Who does the child live with? Date of Birth: / / Male Female New Student Returning student School: Teachers Name: Grade: How did you hear about us? In case of emergency, contact: Relationship to student: Phone: Name of other person authorized to pick-up the student: Relationship to student: Phone: Name of other person authorized to pick-up the student: Relationship to student: Phone: Any health information (physical, psychological or otherwise) we should know about that could impact your child s ability to participate? Include any habits, fears, etc. that will better help us meet the individual needs of your child. List any food allergies

WAIVER AND RELEASE OF LIABILITY 2 My name is and I am the parent/guardian of (if student is under 18). I am entering into the following Release and Waiver Agreement with Capoeira Karkara Cultural Arts Center, Inc. (herein called CKCAC), Sara da Conceicao, Alberto da Conceicao and all other instructors at CKCAC, as well as my/my child s fellow students in the capoeira classes, specialty classes and workshops, after school classes or other functions that I/my child am participating in. I understand that I am signing this Release and Waiver Agreement in consideration for and as a requirement of my participating in any classes, after school classes, workshop or other functions at CKCAC whether located at any capoeira facility or other location(s). I understand that I/my child will be participating in an activity that has a potential for physical injury. Because this activity is inherently dangerous, I, for myself/child and on behalf of my heirs, assigns, and personal representatives, hereby RELEASE AND HOLD HARMLESS Capoeira Karkara Cultural Arts Center, Inc., their officers, officials, agents and/or employees, or other participants (CKCAC), from any and all liability, claims, damages, costs expenses, demands, and attorney fees, actions or causes of actions unknown or known, past present or future, related to, arising out of, or are in any way connected with my participation with CKCAC with respect to any and all injury or disability to myself/child including bodily injury, death, or loss/damage to personal property. I understand that participation in capoeira classes and all other activities inside and outside CKCAC involves physical activity and as such carries with it the risk of injury. Should an injury occur, any and all medical expenses incurred are the sole responsibility of the participant or participant s family, this includes all activities inside and outside this facility. I certify that I (and/or my child) have no limitations/conditions and am fully able to participate in this activity. Yes No (If no, refer to Registration Form to list any physical or other health limitations). I acknowledge that failure to disclose any health conditions may result in injury and I hereby RELEASE AND HOLD HARMLESS CKCAC from any and all liability associated with any harm or injury resulting from my failure to disclose such health condition. I hereby authorize CKCAC, Alberto Conceicao (C.Mestre Betinho), Sara Conceicao, and all authorized drivers to transport my child from school to Capoeira Karkara (CKCAC), to medical facilities, including urgent care and hospital facilities, other participating schools that we pick up from, and from the academy to any local field trips that have been planned in advance. In doing so, I hereby expressly waive and release any and all rights or claims of any nature whatsoever I may have against the driver, teachers, administrators, and employees of CKCAC, arising out of, in connection with, or resulting from the school activities referred to above. I have read, fully understand, and agree with the terms of this Waiver and Release of Liability. I assume the risk and danger of injury to myself/child while participating at CKCAC or in any event in connection with CKCAC. This Release and Waiver Agreement executed this day of, 20. Student Name Student Signature Parent/Guardian Name (if student is under 18) Parent/Guardian Signature

Welcome to the 2016-2017 After-School Capoeira Program Our Karkara Kids have fun developing self-esteem, self-control and leadership skills while learning capoeira. Our active, fun, and structured after school program not only teaches selfdefense, acrobatics, music, dance, language and culture, but also; respect, self-control, courage, self-confidence, physical coordination and balance. We are not a daycare, we are much more. Your child will have a blast while receiving top quality training in martial arts, music, acrobatics, Brazilian language and culture and yoga. Don t be surprised to see attitude and behavior changes at home and in school as your child learns the value of respect and self-discipline and is given a daily opportunity to get out that extra energy in a positive way. A typical day will include time for snack and homework and instruction in one or more of the following areas: capoeira martial arts and dance techniques, music, acrobatics, yoga, Portuguese, strength and trust-building games. 3 RULES AND REGULATIONS FEES FOR AFTER-SCHOOL PROGRAM: $ 320.50 per month* for a total of 10 payments 10% sibling discount *For students entering our program after the start of the school year, your monthly payment amount will vary depending on your start date. This monthly fee includes transportation from school to the academy, and half-day and full day camps on many school days and all early release days at NO EXTRA CHARGE. $320.50 will be charged on the 15 th day of each month, for a total of 10 monthly payments. Payment Breakdown Schedule for 2016-2017 School Year: Month Amount # of Days # of Half Days # of Full Days Half Day Camp Full Day Camp AUGUST $ 208.00 13 0 0 ---- ----- SEPTEMBER $ 342.50 20 1 0 9/15 ----- OCTOBER $ 392.00 17 1 3 10/13 10/3,10/12,10/21 NOVEMBER $ 343.50 16 1 2 11/03 11/18,11/11 DECEMBER $ 262.50 15 1 0 12/8 ----- JANUARY $ 288.50 16 0 1 ---- 01/16 FEBRUARY $ 343.00 18 1 1 02/12 02/20 MARCH $ 304.50 17 0 1 ---- 03/17 APRIL $ 336.50 19 0 1 ---- 04/14 MAY $ 352.00 22 0 0 ---- ------ JUNE $ 32.00 02 0 0 ---- -----

Your monthly payment includes: 4 Transportation from school to the academy Afterschool instruction from school release time until 6:00 pm, Monday Friday from August 15 th June 2nd (Time for snack, homework, and at least one capoeira class) Half day camp on all early release days (5 total - see payment breakdown schedule for dates) students must bring lunch and 1 snack Full day camp on most no-school days (9 total - see payment breakdown schedule for dates). Drop off time begins at 7:30 am. Scheduled activities begin at 9:00 AM and continue until 4 pm. Pick up time is between 4 and 6 pm. Students must bring lunch and 2 snacks and must wear their uniform shirt and bring their uniform pants for class. You will be notified if anything additional is needed for any scheduled outings. *If there is an additional fee for a special field trip we will let you know in advance. NO-SCHOOL DAYS NOT INCLUDED IN TUITION PRICE: We will not offer day camp on the major holidays listed below, or Thanksgiving Break (November 23-25) or Winter Break (December 23-January 6). We WILL offer Spring Camp from March 20-24 at an additional cost. **NEW THIS YEAR** WE WILL INCLUDE DAY CAMP ON FRIDAY MARCH 17th (1st day of Spring Break) AT NO EXTRA COST TO YOU. Capoeira Karkara will be closed on the following major holidays: Labor Day Thanksgiving Day Christmas Eve, Christmas Day New Year s Eve, New Year s Day Memorial Day Independence Day LATE PICK UP POLICY Our program ends at 6:00pm, but we are extending our pick up hours as we understand that there will sometimes be delays, so we are giving you an extra 14 minutes to arrive without being charged. If any time you pick up your child on or after 6:15 pm, you will be charged $10. For every 15 extra minutes that you are late there will be an additional charge of $10. All charges will be automatically processed on the 15th of every month using your cedit card on file. PAYMENT POLICY: All payments are collected through our automated payment service. Please fill out the attached form with your credit card information. A completed registration form must be on file with the program prior to the first day of attendance. REGISTRATION FEES: New students: An $80 non-refundable registration fee (plus tax) is due on the date of registration for the after school program. This fee includes a new uniform and a raw (white) cord. Returning students: A $20 non-refundable registration fee (plus tax) is due on the date of registration for any regular monthly classes, afterschool program, or camp. This fee includes a new shirt. CANCELLATIONS: You may cancel your scheduled payments anytime by submitting a 30 day written notice, and you will be required to pay any outstanding balance for days attended. DECLINED PAYMENTS: There is a $15.00 charge for all declined payments. REFUNDS: No refunds or credits will be given for missed classes. Lack of attendance does not change the amount you will be charged monthly. No refunds are given for uniforms. PHOTOGRAPHS: The student/parent gives permission to be photographed and/or video recorded during participation in any activity in connection with Capoeira Karkara. CKCAC retains all rights of ownership of any photographs obtained at any event the student participates in.

5 ABSENCES: If possible, please give 24 hour notice if your child will be absent from school and will not be picked up by our van on any given day. If you have a doctor s appointment, you may drop your child off at any time to attend the rest of the afterschool programming. If you cannot give 24 hours notice, call (561) 737-3425 or email info@capokusa.com to let us know as soon as possible. UNIFORMS: White uniforms are required for all capoeira classes taught during the week. On Fridays and Saturdays only, students may wear colored uniforms to class. Students not wearing the Capoeira Karkara shirt and pants/cord may not be able to participate in classes. INCLEMENT WEATHER: On days that public schools are closed due to inclement weather, we will be closed. If public schools closed mid-day, it is the parent s responsibility to retrieve their children and care for them. HEALTH: Any limitation in the ability to participate due to a medical condition must be noted on the Registration Form. Failure to identify any health condition will result in CKCAK treating the student as if he/she has no existing health condition. SNACKS: Each day you must send an extra healthy snack with your child. We will have snacks available for purchase in the event that you cannot provide a snack. No refrigeration or microwave is available for safety purposes. We always have water available to students. WAITING AREA: People not participating in class but wish to stay in the facility during a class must stay in the waiting area only. Only participating students are allowed on the floor at any time. Anyone who chooses to stay in the waiting area may observe classes but may not interact with students, teachers or interfere with class in any way. DISCIPLINE: Students must be respectful at all times. This includes self-respect, respect for fellow students, respect for instructors, and respect for the space we train in. Parents are expected to support us in enforcing this policy. The following is your payment schedule for your After School payments to be made from your card ending in. You will be emailed a receipt each time your card on file is charged. PAYMENT DATE PAYMENT AMOUNT I have read, understand and agree to all terms outlined in this rules and regulations packet. Parent name: Parent Signature: Date:

6 Capoeira Karkara Cultural Arts Center, Inc. Recurring Payment Authorization Form Recurring Payments Will Make Your Life Easier: It s convenient (saving you time and postage) Your payment is always on time (even if you re out of town), eliminating late charges Here s How Recurring Payments Work: You authorize regularly scheduled charges to your Visa, MasterCard, American Express or Discover card. You will be charged the amount indicate below each billing period. A receipt will be emailed to you and each charge will appear on your statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. Please complete the information below: I authorize Capoeira Karkara Cultural Arts Center, Inc. to charge my credit card (full name) indicated below for every starting on and ending on (day) (date: MM/DD/YY) (date: MM/DD/YY) for payment of my After School Program for for a total of monthly payments. (Student Name) Billing Address Phone# City, State, Zip Email Account Type: Visa MasterCard AMEX Discover Cardholder Name Account Number Expiration Date CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of termination of this authorization 30 days in advance of the date of termination. I will notify the business of any changes in my account information at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. This payment authorization is for the type of bill indicated above, as well as any decline fees, late pick-up fees, or outstanding balance should there be one if I decide to cancel before the end of the school year. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; provided the transactions correspond to the terms indicated in this authorization form. SIGNATURE DATE Registration Fee Amount: Authorized? Y or N Form of Pmt: Date received: